A person’s health is largely dependent on factors outside the health care system, including where they live, learn, work and play—known as social determinants of health. As health care costs continue to pressure state budgets, state lawmakers seek policy options to address social determinants that may be contributing to costly preventable chronic diseases and conditions. One option involves improving access to stable, affordable, and healthy housing.
Mitigating Home Hazards
While significant progress has been made in the U.S. since the 1970s, lead exposure remains a top health concern in the U.S., particularly for young children. According to the U.S. Department of Housing and Urban Development, as many as 23 million homes in the U.S. have peeling or chipping lead-based paint and/or high levels of lead in dust. Most of these homes were built before 1978 when lead-based paint was banned for residential use.
Lead exposure is particularly dangerous for young children as their bodies are more sensitive to lead exposure. Children with increased levels of lead in their blood may experience different effects including slower growth and development, lower IQ scores, decreased academic performance as well as other potential long-term harm. According to the Centers for Disease Control and Prevention (CDC), children from low-income families and communities of color are more at risk for lead exposure, partly due to housing in low-income areas being more likely to be older and contain lead hazards.
According to the CDC, asthma affects more than 24 million Americans, including 5.5 million children, with a higher prevalence among Black and low-income children. Researchers at the CDC estimated that asthma accounts for at least $80 billion in national health care costs annually. Although asthma cannot be cured, it can be effectively managed with services based on guidelines developed by the National Heart, Lung, and Blood Institute. These guidelines include methods for reducing exposure to indoor asthma triggers in housing such as pests, tobacco smoke and mold.
Strategies to limit lead exposure and reduce housing conditions that exacerbate asthma can be aligned through healthy housing efforts. State policymakers have legislative and regulatory options available to help improve access to healthy housing as well as options to leverage Medicaid and State Children’s Health Insurance Program (CHIP) programs to provide services that mitigate housing hazards and provide necessary treatment.
Starting in the 1970s, federal legislation and regulation reduced allowable levels of lead in gasoline, paint, drinking water and food containers, resulting in significant reductions of blood lead levels in children. In fact, the prevention of child lead poisoning was recognized as one of the 10 great public health achievements in the U.S. from 2001 to 2010. Despite this significant progress in reducing overall blood lead levels in children, lead exposure continues to negatively affect young children, particularly children in low-income urban areas with older housing options.
Congress enacted the Residential Lead-Based Paint Hazard Reduction Act of 1992 (42 U.S.C. §4851-56), or Title X, to attempt to address hazards posed by older housing not covered in earlier federal legislation. Title X requires the removal of lead hazards in federally assisted housing and for private housing, contains disclosure requirements and other measures to reduce risk of exposure. For any housing built before 1978, sellers and landlords are required to provide information regarding lead-based paint hazards and information regarding any potential presence of identified lead hazards in the home. The federal legislation also required the adoption of lead safety requirements for federally assisted housing, leading to government assisted housing being safer than non-assisted low-income housing in 2000.
In 2010, the Environmental Protection Agency (EPA) finalized the Lead-Based Paint Renovation, Repair and Painting (RRP) Rule to provide further protections from lead-based paint hazards. The rule establishes uniform training and certification requirements for contractors performing renovations, repairs and painting projects that disturb lead paint in homes, although the EPA’s enforcement of the rule has been limited.
State legislatures have adopted a variety of policies to mitigate lead hazards and to complement federal policies (please see NCSL’s summary of state lead-based paint statutes here). State laws include a variety of provisions such as: implementing comprehensive lead exposure prevention programs; complying with federal requirements; certifying or accrediting of inspectors and lead abatement professionals; and blood lead level screening requirements.
These laws generally fall into two categories: primary prevention and secondary prevention. Primary prevention efforts aim to identify and remove hazards before children are exposed. As there has been no safe level of lead exposure identified, primary prevention is the most effective way to stop childhood lead exposure. Examples of primary prevention strategies include requiring property owners to control lead hazards in rental housing that may house children and imposing civil penalties for noncompliance. State laws can also require the licensure or certification of professionals used for lead abatement and mitigation activities to assure hazards are completely removed safely.
Secondary prevention efforts aim to identify and treat children after they already have elevated blood lead levels. When primary prevention is not available or falls short, early detection, diagnosis and intervention are critical to prevent worsening health outcomes. Many states have adopted laws focused on secondary prevention, such as increasing blood lead screening rates for children to better identify children in need of services and mitigate potential long-term health outcomes.
Ohio uses several strategies in state law and regulations, including requiring public health investigations when a child has been exposed to lead to determine the source of lead exposure as well as risk assessments of residences identified as potential sources of the lead exposure. State law requires the licensure of lead hazard control professionals, and the state director of health is required to monitor the quality of work of these professionals and refer cases to the attorney general if necessary.
Maryland law incorporates many primary prevention strategies as well as secondary prevention. Maryland requires proactive inspections of rental property and remediation of hazards in older properties (Maryland Reduction of Lead Risk in Housing law). Other polices enacted by Maryland include requiring certification of property owner compliance with lead laws before allowing the collection of rent in court as well as strong state law and local code enforcement, including potential heavy fines. In addition, Maryland enacted HB 1033 in 2011 to establish mandatory lead dust testing as lead-contaminated dust is the most common source of exposure for children. Through these efforts, complemented by secondary prevention strategies, Maryland has been able to decrease the number of children in the state with elevated blood- lead levels by 98% since 1993.
Some states, such as Maine, require universal screening and reporting for all children at ages 1 and 2 regardless of potential risk of exposure. In contrast, some states have enacted a targeted screening requirement to focus on geographic areas in the state particularly impacted by lead hazards. Before 2015, Maryland used a targeted approach but changed to universal screening requirements to better identify affected children as risk factors changed and new sources of potential lead exposure were identified. The CDC’s most recent guidance from 2009 recommends data-driven targeted screening based on local assessments of risk.
Medicaid and CHIP Policy Options
Covering over 35% of children in the United States, Medicaid can provide access to critical diagnostic services for children under the age of 21. Medicaid can be used to improve lead exposure prevention and response strategies, like lead abatement and blood lead level screening requirements, and subsequent treatment. Similarly, Medicaid provides diagnosis and treatment for asthma and related conditions, which creates opportunities to provide preventive care and proactive screening for home hazards. Medicaid can be a tool for state legislatures looking to improve population health in part because of the large number of children covered by Medicaid and because of the opportunity for federal matching of state funds, as the federal government provides a minimum of 50% towards Medicaid services.
Paying for Screening and Treatment
The Early, Periodic, Screening, Diagnostic and Treatment (EPSDT) benefit in the Medicaid program provides comprehensive health services to children by covering all screening and treatment services that are deemed medically necessary. The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for oversight of the Medicaid program, requires screening tests at ages 1 and 2 in alignment with the Bright Futures Guidelines recommendations. State Medicaid programs are required to cover diagnosis and treatment for asthma. In addition, CMS requires children between the ages of 2 and 6 with no record of a blood lead screening test to be screened for lead.
Because EPSDT is a comprehensive benefit, all services that are medically necessary for treatment of increased blood lead levels and asthma care are covered by Medicaid, even if those services are not otherwise covered under a state’s Medicaid program. To connect children with needed treatment services, states can use case management services to refer children to treatment and coordinate services. Case managers can help provide education regarding lead hazards, cleaning techniques and supplies. Medicaid can pay for on-site home assessments conducted by certified lead risk assessors to identify potential lead exposure sources. Maryland recently enacted legislation to reduce the blood lead level threshold necessary to refer a child for case management services.
Lead exposure and prevalence are often concentrated in areas of a state, such as areas that are primarily low-income or disproportionately people of color. State policymakers may consider a targeted testing approach to improve screening in high-risk areas and populations. CMS allows states to develop targeted plans to ensure children who are at higher risk are tested. Arizona is currently the only state with a targeted approach approved by CMS. Using data from the health department, Arizona developed a ZIP code risk index and tests all children living in high-risk zip codes in accordance with EPSDT requirements. Universal screening policies are more protective because lead-based paint can be present in any home built before 1978 and there are other sources of lead exposure such as imported pottery, medicines, and dust brought home from work settings.
Other Medicaid Options
Section 1115 waivers provide another opportunity for states to provide coverage of lead abatement and screening activities. Section 1115 waivers allow states to waive certain Medicaid requirements in order to design experimental or demonstration programs to meet their state’s needs. For example, Michigan used an 1115 waiver to respond to the Flint water crisis starting in 2015. Michigan’s 1115 waiver has since been amended to include resources for lead abatement from all sources in the home, not just water pipes.
These 1115 waivers can also be used to address other housing health hazards such as asthma triggers, which can include pests, tobacco smoke and mold. People with low incomes are disproportionately affected by asthma and most low-income children with asthma are enrolled in Medicaid or the Children’s Health Insurance Program. Massachusetts uses an 1115 waiver to provide prevention services not typically covered by Medicaid including home visits, care coordination and case management, supplies to reduce environmental triggers (such as high-efficiency vacuums and air filters, and mite-proof mattress covers), and pest management supplies and services. Missouri’s Medicaid program allows for one hour of asthma education and two asthma environmental assessments per year. Oregon uses the targeted case management Medicaid benefit to provide these services to children with asthma.
Services provided through Medicaid to help better manage asthma can potentially lead to cost savings for states. For example, Rhode Island’s Home Asthma Response Program (HARP) found a 75% reduction in asthma-related hospital visits for individuals participating in the program, which included asthma education and supplies to reduce triggers.
Health Services Initiatives
Access to funding for actual removal and abatement of housing hazards is often a barrier for states in achieving healthy housing goals. CHIP allows states to use CHIP funding to implement health services initiatives (HSIs) for improving the health of low-income children (§ 2105(a)(1)(D)(ii) of the Social Security Act). States receive annual allotments, similar to a block grant, to fund their CHIP programs. The allotment includes funding for administration: A state may use up to 10% of its total CHIP funding to cover administration costs for the program. For any funding remaining within that 10% cap, a state can choose to apply it to an HSI. In addition, CHIP receives an enhanced federal matching rate compared to Medicaid, with the minimum 65% federal contribution. An HSI can provide a funding source to remove hazards from homes.
States have the option to choose the type and scope of HSIs. As of 2019, according to the Medicaid and CHIP Payment and Access Commission (MACPAC), 24 states had 71 HSIs approved for a variety of activities, including six states approved for programs to promote lead screening, treatment and abatement, and one state using an HSI to address asthma triggers. Lead abatement programs can include educating families about lead exposure, testing, and case management services.
Indiana has an HSI which supports targeted lead abatement activities to mitigate all lead risks; services can be rendered to the home and surrounding property. Missouri’s HSI provides support to local public health agencies’ efforts to monitor and manage children up to age 6 with elevated blood-lead levels. Michigan’s and Ohio’s HSIs address lead abatement through removal and replacement of lead-painted components such as doors, windows, and floors, stabilizing paint, and soil replacement or covering. The installation of water filters and relocation per diems for families is also covered. Ohio’s HSI further provides funding to support the housing registry for lead levels in rental properties.
HSIs can have many facets. For example, Maryland has a multi-part initiative, which expands identification and abatement programs for children in low-income families and provides environmental assessments and education to families regarding lead hazards and asthma triggers. The HSI is targeted to nine counties for community health workers to provide education support and outreach for children with lead poisoning and asthma.
Ongoing Challenges and Opportunities
NCSL interviewed several state officials and reviewed available literature to identify examples of successes as well as ongoing challenges that may present opportunities for state policymakers to address access to healthy housing. NCSL had discussions with state lead officials in Connecticut, Maine, Louisiana, Minnesota and Ohio and Medicaid officials from Maryland, Oregon, and Rhode Island. Themes from these conversations, along with some themes from the available literature, are summarized below.
While primary prevention is the most effective strategy and opportunities exist for states to adopt primary prevention strategies in statute, enforcement can be difficult as the needed resources are often not available. States may lack both the funding and the personnel to comply with enforcement requirements. For example, the department responsible for enforcement activities in Maryland is chronically understaffed, with a steady decline of inspectors in the state department from 2010 to 2016. While Maryland enacted legislation to increase environmental investigations, there is an outstanding question of whether they will be able to adequately staff to meet the need. Maine enacted a screening statute and expanded to universal testing for 1- and 2-year-olds in 2019 but continues to struggle to meet screening targets.
Noncompliance with state laws also presents a challenge. Many state laws require disclosure of lead hazards, however not all property owners comply with disclosure requirements—plus some property owners are unaware of lead hazards in their property. Increased identification of lead hazards could be achieved through mandatory inspections, which could be funded by state or local governments. As lead hazard abatement activities cross federal, state, and local authorities and involve many different entities, partnering with local jurisdictions on enforcement activities could be an option to address some of these challenges.
Cross-sector collaboration and education can help access sustainable financing to improve access to healthy housing and mitigating hazards. This report, from Regional Asthma Management & Prevention (RAMP), discusses how partnerships improved efforts to obtain sustainable financing for asthma trigger remediation. While the RAMP report is specific to asthma, this theme was echoed in NCSL’s conversations with state officials. For example, Connecticut is working to implement a statewide model of integrated weatherization and healthy housing activities, to include both lead abatement and asthma trigger mitigation. According to the U.S. Department of Energy, promising practices in integration and cross-sector collaboration have allowed for more comprehensive healthy homes interventions, with evidence suggesting energy savings and better health outcomes.
When it comes to obtaining Medicaid funding in particular, state officials emphasized the need to demonstrate a clear return on investment. Rhode Island employed this principle as a key strategy to obtain Medicaid funding for its Home Asthma Response Program (HARP) initiative, by demonstrating that money invested into reducing preventable emergency department and hospital visits gets returned with additional savings. These initiatives can also reduce long-term costs: Rhode Island’s program demonstrated improved asthma control, reductions in missed school and work days, and improved quality of life.
When additional funding is not available or limited, states can use their existing Medicaid infrastructure to achieve lead screening improvements. Kentucky requires its Medicaid managed care organizations to track and report their performance on the lead screening measures and provides incentive payments when key thresholds are met. Other states, such as New Jersey, may impose sanctions on managed care organizations that fail to meet a lead screening goal.
While much work remains to reduce lead exposure and alleviate asthma triggers, progress has been made and continues through federal and state actions. Many policy options are available to state policymakers and states may continue to develop coordinated strategies to increase access to healthy housing.